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An overview on the nutrition transition and its health implications:the Bellagio meeting
Introduction
This supplement is based on papers presented at the
Bellagio Conference on the Nutrition Transition. The
meeting was organised to allow us to assess current low-
and moderate-income industrialising countries’ experi-
ence related to the nutrition transition and provide ideas
for pushing forth a broader public health agenda in this
area. More specifically, the meeting focused on changes in
patterns of behaviour (diet, smoking, drinking, activity)
that lead to rapid increases in obesity, cardiovascular
disease (CVD) and cancer. The nutrition-related non-
communicable diseases (NR-NCDs) were once referred to
as diseases of affluence. For decades this has not been true
among higher-income countries, and as we now show,
this is increasingly not the case in the lower- and middle-
income countries.
Two historic processes of change occur simultaneous to
or precede the nutrition transition. One is the demo-
graphic transition – the shift from a pattern of high fertility
and high mortality to one of low fertility and low mortality
(typical of modern industrialised countries). Even more
directly relevant is the epidemiological transition, first
described by Omran1: the shift from a pattern of high
prevalence of infectious diseases associated with malnu-
trition, and periodic famine and poor environmental
sanitation, to a pattern of high prevalence of chronic and
degenerative diseases associated with urban–industrial
lifestyles. A third pattern of delayed degenerative diseases
has been formulated more recently (e.g. Olshansky and
Ault2). Accompanying this progression is a major shift in
age-specific mortality patterns and a consequent increase
in life expectancy. Interpretations of the demographic and
epidemiological transitions share a focus with the nutrition
transition on the ways in which populations move from
one pattern to the next.
Similarly, large shifts have occurred in dietary and
physical activity and inactivity patterns. These changes are
reflected in nutritional outcomes, such as changes in
average stature and body composition. Modern societies
seem to be converging on a pattern of diet high in
saturated fat, sugar and refined foods and low in fibre –
often termed the ‘Western diet’. Many see this dietary
pattern to be associated with high levels of chronic and
degenerative diseases and with reduced disability-free
time. These three relationships are presented in Fig. 1.
Human diet and activity patterns and nutritional status
have undergone a sequence of major shifts, defined as
broad patterns of food use and their corresponding
nutrition-related diseases. Over the last three centuries, the
pace of dietary and activity change appears to have
accelerated, to varying degrees in different regions of the
world. Further, dietary and activity changes are paralleled
by major changes in health status, as well as by major
demographic and socio-economic changes. Obesity
emerges early in these shifting conditions as does the
level and age composition of morbidity and mortality. We
can think of five broad nutrition patterns. They are not
restricted to particular periods of human history. For
convenience, the patterns are outlined as historical
developments; however, ‘earlier’ patterns are not
restricted to the periods in which they first arose but
continue to characterise certain geographic and socio-
economic sub-populations.
Pattern 1: Collecting Food
This diet, which characterises hunter–gatherer popu-
lations, is high in carbohydrates and fibre and low in fat,
especially saturated fat3,4. The proportion of polyunsatu-
rated fat in meat from wild animals is significantly higher
than in meat from modern domesticated animals5. Activity
patterns are very high and little obesity is found among
hunter–gatherer societies. It is important to note that
much of the research on hunter–gatherers is based on
modern hunter–gatherers as there is much less evidence
on pre-historic people.
Pattern 2: Famine
The diet becomes much less varied and subject to larger
variations and periods of acute scarcity of food. These
dietary changes are hypothesised to be associated with
nutritional stress and a reduction in stature (estimated by
some at about 4 inches6,7). During the later phases of this
pattern, social stratification intensifies, and dietary
variation increases according to gender and social status8.
The pattern of famine (as with each of the patterns) has
varied over time and space. Some civilisations are more
successful than others in alleviating famine and chronic
hunger, at least for their more privileged citizens9. The
types of physical activity changed but there was little
change in activity levels during this period.
Pattern 3: Receding Famine
The consumption of fruit, vegetables and animal protein
increases, and starchy staples become less important in the
diet. Many earlier civilisations made great progress in
reducing chronic hunger and famines, but only in the last
third of the last millennium have these changes become
widespread, leading to marked shifts in diet. However,
famines continued well into the eighteenth century in
q The Author 2002
Public Health Nutrition: 5(1A), 93–103 DOI: 10.1079/PHN2001280
portions of Europe and remain common in some regions
of the world. Activity patterns start to shift and inactivity
and leisure become part of the lives of more people.
Pattern 4: Nutrition-related Non-communicable
Disease
A diet high in total fat, cholesterol, sugar and other refined
carbohydrates, and low in polyunsaturated fatty acids and
fibre, and often accompanied by an increasingly sedentary
life, is characteristic of most high-income societies (and of
increasing portions of the population in low-income
societies). This results in increased prevalence of obesity
and contributes to the degenerative diseases that
characterise Omran’s final epidemiological stage.
Pattern 5: Behavioural Change
A new dietary pattern appears to be emerging as a result of
changes in diet, evidently associated with the desire to
prevent or delay degenerative diseases and prolong
health. Whether these changes, instituted in some
countries by consumers and in others also prodded by
government policy, will constitute a large-scale transition
in dietary structure and body composition remains to be
seen10–12. If such a new dietary pattern takes hold, it may
be very important in enhancing ‘successful ageing’; that is,
postponing infirmity and increasing the disability-free life
expectancy13,14.
Our focus is increasingly on patterns 3 to 5, in particular
on the rapid shift in many of the world’s low- and
moderate-income countries from the stage of receding
famine to NR-NCD. Figure 2 presents this focus. The
concern about this period is so great that the term the
Nutrition Transition is synonymous, for many, with this
shift from Pattern 3 to 4.
In the conference and this journal supplement, the
papers are arranged around several themes. We present
these and note the key issues in each paper.
What has happened in terms of some of the unique
elements of shift in diet, activity, obesity, and other
measures of morbidity and mortality within
different regions of the world?
Many of the papers were country studies that capture the
key trends in diet, physical activity, body composition and
NR-NCD that could be measured on a large-scale basis.
Data are very scarce in many countries, in particular for
diet and physical activity, so the main common
denominator is data on overweight and obesity. Overall
we know that four-fifths of the world’s burden of NR-NCD
comes from the low- and moderate-income countries.
These papers provide some insights into ways that the key
nutritional risk factors have changed.
Latin America
Many countries in this region began their transition earlier
in the past century and certainly entered the NR-NCD stage
far earlier than did other regions. But there is enormous
heterogeneity and countries such as Haiti and sub-
populations in Central America are still in the receding
famine period. Moreover, some such as Mexico really
experienced an accelerated transition in the 1990s.
The case studies are important for showing that the
Fig. 1 Stages of health, nutritional and demographic change
Overview of the nutrition transition and its health implications94
burden of disease has shifted towards the poor for selected
sub-populations in this region. Brazil and Chile, in
particular, were the first to reach this stage. In the case
of Chile, as noted by Albala et al.15, the largest burden of
obesity has already been placed on the poor. Monteiro
et al.16 show how rapidly obesity has replaced under-
nutrition in Brazil and the way the shift in obesity towards
a burden for the poor is occurring for Brazilian women
but not yet for the men. The paper by Albala et al.15
also describes the burden of disease related to obesity in
Chile.
As Rivera et al.17 show, Mexico exhibits a later shift than
the other Latin American countries presented; however, in
a very short period of time it has seen marked increases in
obesity and has displayed a pattern of change where the
prevalence of adult-onset diabetes emerges as very high.
In Mexico over 7% of adults are diabetic. Obesity levels are
very high, almost as high as those observed among
Mexican-Americans residing in the USA. In the US, with its
very high level of obesity, diabetes affects 8% of the
population aged 20 years and older.
The Cuba case study is important for showing how
large-scale macroeconomic changes, in this case caused
by exogenous forces linked with the cessation of subsidies
from the Soviet Union and other causes, can affect energy
imbalance and obesity in a positive manner and can
rapidly alter the health of the population. At the same time
there were adverse effects on nutritional status not
addressed in this paper. The shortage of imported fuel
and foods was linked with a marked shift in total energy
and the proportion of energy from fat. At the same time
physical activity increased and the net effect was a
Fig. 3 Obesity patterns among adults in Latin America. GNP – per capita gross national product (in 1998 US$). Sources: Monteiroet al.16, Rivera et al.17 and Rodrıguez-Ojea et al.18
Fig. 2 Stages of the nutrition transition
Overview of the nutrition transition and its health implications 95
reduced prevalence of obesity. There were not, unfortu-
nately, the types of monitoring survey that allowed one to
understand the health effects of this change in the
prevalence of obesity.
Figures 3 and 4 present data from these papers on
obesity16–18. Figure 4 shows how quickly overweight and
obesity status have emerged in Mexico as a major public
health problem. In Fig. 3 we present the most recent data
on overweight and obesity for males and females. Figure 4
presents the annualised increase in the percentage points
of prevalence for data from countries with comparable
data. Compared with the USA and European countries,
where the annual prevalence increase in overweight and
obesity are about 0.25 each, respectively, the rates of
change are very high in Latin America. Cuba’s data
represent Havana only.
The dietary shifts for this region also are quite different
from those experienced by the other regions. The South
American countries underwent a shift towards a diet high
in animal products long ago. Their fat intake comes more
from saturated fat sources. Also, added sugar intake is
higher in the region. By comparison, in Mexico, the shift in
Fig. 4 Obesity trends among adults in Latin America (the annual percentage point increase in prevalence). GNP – per capita grossnational product (in 1998 US$). Sources: Monteiro et al.16, Rivera et al.17 and Rodrıguez-Ojea et al.18
Fig. 5 Obesity patterns among adults in North Africa/Middle East. GNP – per capita gross national product (in 1998 US$). Sources:Galal19, Benjelloun20, Ghassemi et al.21, Al-Isa22,23, Al-Nuaim et al.24, Al-Mannai25, Shetty26 and Ajlouni et al.27
Overview of the nutrition transition and its health implications96
structure of the diet is dominated by a reduction in cereal
products and tortillas with less clarity in the types of foods
that have replaced these items.
North Africa/Middle East
This region does not possess the depth and quality of
historical data on diet, activity and body composition that
allows for a clear assessment of the timing of the shift in
the nutrition transition stage. In fact, there are so few
systematic data on dietary trends that it is not possible to
get a sense of the role of either shifts in the structure and
level of dietary intake or physical activity and inactivity in
the current high levels of obesity and NR-NCDs. All of the
authors discussed the possibility that a culture based on a
desire for a larger body size and less activity may be
important, but again this topic has not been studied.
Galal’s paper19 on Egypt provides evidence of a very
high level of overweight and obesity in Egypt, but this
paper provides no sense of when obesity emerged as a
public health problem in Egypt. Egypt suffers from very
high rates of hypertension, diabetes and other obesity co-
morbidities. Women are more likely to be obese but the
prevalence among men is also very high (overweight and
obesity affect about two-thirds of urban and one-third of
rural men, and over 80% of urban and 56% of rural
women).
Benjelloun20 documents a similar very rapid increase in
obesity and a shift towards an energy-dense diet in
Morocco. Although the association with education is
inverse, income is still positively associated with obesity in
Morocco. Females are disproportionately affected, but
obesity is also a major problem among men.
Ghassemi et al.21 show that, despite a lack of sustained
economic growth, over-consumption of a less energy-
dense diet is linked with obesity, in particular in the urban
areas. Even in rural areas, over a quarter of adults (men
and women) are overweight or obese, while in urban
areas the rates are higher. Overall, more than 28% of
Iranian men and 40% of women are overweight or obese.
Diabetes and other obesity co-morbidities are becoming
significant public health problems.
We summarise the patterns and trends of overweight
and obesity in this region in Figs 519–27 and 620,22,28. Trend
data are available for only a few countries in the region.
Sub-Saharan Africa
This is the poorest region in the world. Marked by political
and economic instability and great variations in natural
resources, many of the poorest countries in the world
reside in this region. Again, there are no systematic
national surveys that have obtained dietary and activity
data and only minimal data on dietary trends, but there are
some good obesity and NR-NCD morbidity and mortality
data (Fig. 7)26,28,29. Yet even among the poorest, large
proportions of the population are shifting towards the NR-
NCD patterns found in other regions of the low- and
moderate-income world. At the same time the region faces
the scourge of HIV/AIDS in a very intense manner. The
critical question posed by the papers presented here is: for
those adults who survive HIV/AIDS, will they have a
Fig. 6 Obesity trends among adults in North Africa/Middle East (the annual percentage point increase in prevalence). GNP – per capitagross national product (in 1998 US$). Sources: Benjelloun20, Al-Isa22,23 and Hodge et al.28
Overview of the nutrition transition and its health implications 97
burden of disease linked with high levels of NR-NCDs and
will this burden affect their capacity to care for the future
generation of adults?
Bourne et al.’s paper29 provides a convincing picture of
a lifestyle that has led to very high levels of obesity and
overweight among black South Africans (Fig. 7). There has
been a marked increase in the fat density of their diet and
also in the proportion of adults, in particular women, who
are overweight or obese (close to 60%). Over a quarter of
men fit this same category and close to a quarter of the
population is hypertensive. Bourne has also presented
data (not in her paper) that reflect the large changes in the
age composition of South Africa that will occur over the
next two decades as the full impact of the HIV/AIDS
epidemic is felt.
Tanzania, one of the poorest countries in sub-Saharan
Africa, faces similar problems although in a more limited
manner30. Diabetes and hypertension are clearly diseases
of the affluent still, but as we show in Fig. 8 with
Demographic and Health Survey (DHS) data, obesity is a
problem among all groups in Tanzania. DHS covers
women of childbearing age with pre-school children, a
very young sample, and collected weight and height data
for many sub-Saharan African countries in a comparable
manner. Obesity is increasing and over 13% of the
sampled women were overweight or obese in Tanzania.
Fig. 7 Obesity patterns among adults in sub-Saharan Africa. GNP – per capita gross national product (in 1998 US$). Sources: Shetty26,Hodge et al.28 and Bourne et al.29
Fig. 8 DHS trends for females in sub-Saharan Africa. GNP – per capita gross national product (in 1998 US$). *, Sample size
Overview of the nutrition transition and its health implications98
Asia
Better dietary data are found in this region and even good
activity data for China. Thus it has been possible to
document, in papers presented here and elsewhere, that
the period 1985–2000 saw one of the great shifts in dietary
and physical activity patterns for large proportions of the
population in most countries. Overweight and obesity are
still emerging as major public health problems yet the co-
morbidities are very high, as the proportion of body fat in
Asian adults was 5–6% higher for a given body mass index
(BMI) in the 1920s than in equivalent white adults in
Europe and the USA. Du and his co-authors31 show the
Chinese shift towards an energy-dense diet, high levels of
sedentarianism and increased obesity. These changes are
still mainly found among adults and hypertension levels
are very high. Diabetes and CVD are emerging as serious
problems. China fits the East Asian pattern where very
high levels of hypertension emerge first and diabetes and
CVD are seen later.
India is at a much earlier stage of the transition and only
the urban areas are greatly affected. Nonetheless, the
burden of CVD is great and there is evidence of a large
Fig. 10 Obesity trends among adults in Asia (the annual percentage point increase in prevalence). GNP – per capita gross national pro-duct (in 1998 US$). Sources: Du et al.31; Kosulwat32 and Lee et al.34
Fig. 9 Obesity patterns among adults in Asia. GNP – per capita gross national product (in 1998 US$). Sources: Du et al.31, Kosulwat32,Noor33, Lee et al.34; Shetty35, Solon36 and Popkin et al.37
Overview of the nutrition transition and its health implications 99
increase in NR-NCDs in India. The absolute number of
new diabetic cases in India is larger than in any other
country of the world. Together, India and China comprise
the majority of new cases of diabetes in the world. India’s
dietary pattern includes very high dairy and sugar
consumption and there are marked increases in energy
density of the diet, at both urban and rural levels.
Kosulwat32 carefully documents the remarkable social
and economic transitions Thailand has undergone. She
shows how obesity even among children and adolescents
is increasing dramatically and similar changes among
adults are very rapid (Fig. 10). Consumption of animal
products and energy from fat have increased markedly
and carbohydrate intake has shifted downward as part of a
marked change in the structure of the diet towards one
dominated by animal products. At the same time, there is a
positive increase in fruit and vegetable intake.
As Noor33 shows, there are much fewer data for
Malaysia so food balance and other data are used and less
clarity is provided about the dynamic changes in the
Malaysian diet and lifestyle. He points to one important
dimension in Malaysia – very high levels of fast food
intake and evidence of high overweight and obesity levels
among males and females.
South Korea, the highest-income country represented in
this supplement, provides a unique example of the good
things a country can do to preserve the healthful elements
of its cuisine34. A combination of large-scale training of
housewives in preparing the traditional low-fat, high-
vegetable cuisine coupled with strong social marketing
has led to very low fat and high vegetable intake levels.
Obesity is considerably below that expected for a country
with its high income level, as is the percentage of energy
from fat. Among all of the countries represented in this
meeting and others we know, South Korea has done the
best job of preserving the healthful dimensions of its
traditional cuisine.
The obesity patterns and trends are summarised in Figs
931–37 and 1031,32,34 for countries from this region. Obesity
and overweight levels are lower than those in many of the
other regions and countries. However, the high levels of
NR-NCDs in this region are caused by these changes in
diet, activity and body composition, so the disease impact
of the shifts towards a high energy-dense diet and
sedentarianism and obesity are most important.
What is unique about the experience in lower- and
middle-income less-industrialised countries
compared with the very-high-income industrialised
countries?
Is the speed of change greater today?
Is there anything about the great rapidity of change in diet,
activity and body composition that matters? What does the
high prevalence of the undernutrition-and-overweight
combination in the same household mean in this context?
My paper attempts to summarise current knowledge on
these topics38. While there is no study that clearly explores
these points, extant data from Europe and the USA would
lead us to believe that the rates of change in diet, activity
and obesity in the developing world today are far beyond
those experienced earlier by these countries. As the figures
have shown, the increased percentage points in the
prevalence of overweight and obesity per year are much
higher than found in Europe and the US over the past
several decades. In a very short time many low- and
middle-income countries have attained rates of over-
weight and obesity greater than or equal to those of the
USA and Western Europe.
Is the biology different?
There is limited but strong evidence that the biology is
indeed different. Do we need different BMI cut-off points
for sub-population groups and is this based on biological
differences or just adiposity measurement that is missed
with the use of BMI? That is, do we just have such
imprecise measurement that this is the problem? Again
there is evidence from a range of body composition and
BMI–disease studies that would lead us to believe that the
answer is yes. That is, Asians, Africans and Latin Americans
are more likely than whites in the USA and Europe to have
greater body fat and central fat for the same BMI and to
have a higher likelihood of experiencing CVD outcomes
of importance at lower BMI levels.
In addition, I note that there is the highly suggestive
literature on issues related to foetal and infant insults.
Termed the foetal origins or infant programming literature,
this literature suggests that a rapid shift towards energy
imbalance preceded by high levels of thin babies and
infant stunting will have important long-term effects in
increasing the probability that the subsequent energy
imbalance leads to CVD and various conditions linked
with CVD.
How do we interpret the high levels of both
undernutrition and overweight in the same
household and are there important programmatic
issues related to this topic and that of managing
undernutrition during this rapid transition?
With the problems of undernutrition predominating, we
are now facing this new shift in many countries. This
brings up programme and policy concerns. One issue is
the shift towards households with under- and overweight.
How do we explain this? Doak39 shows it is a non-random
systematic set of factors (higher income, urban residence)
and other social factors that are related to this type of
household.
The second is the issue of food and nutrition
programme design. How do we get policy makers to
focus on prevention of poor dietary and activity patterns
and accelerated obesity? How do the politics of hunger
interact with these new concerns? Are these problems of
Overview of the nutrition transition and its health implications100
NR-NCD, etc. seen as the purview of treatment and not
prevention, and how do we change that? Are there many
examples where current programmes based on the needs
of the hungry and undernourished are actually hurting the
nutritional status of the recipients because they are
focused on problems of undernutrition, but the pro-
gramme recipients are becoming obese? Uauy and Kain40
show that we must be very careful in implementing
feeding programmes for marginally undernourished
children during advanced stages of this transition.
Are there unique points about the CVD epidemic to
consider?
Reddy41 shows that the most globally pervasive change
among these health transitions has been the rising burden
of non-communicable diseases (NCDs). He shows how
the rising burdens of CVD exemplify the high costs that
unchecked epidemics of NCDs will impose on healthcare
systems, and the adverse effects on development that
would result from mid-life death and disability. His paper
provides some sense of the temporal relationship between
the various changes in the key obesity co-morbidities:
hypertension, dislipidaemia, diabetes and CVD. In
particular, he gives some sense that while the profile of
CVD varies among the developing countries, there is a
general progression from a large burden of rheumatic
heart disease, as well as infectious and nutritional
cardiomyopathies in the early stages to hypertension,
then to haemorrhagic stroke and hypertensive heart
disease, and finally these are largely replaced by
thrombotic strokes and coronary heart disease. His paper
also argues that the risk associated with obesity, poor diet
and sedentarianism worsens as one shifts to the right on
the distribution for each element. He argues that there is
no clear cut-off beyond which risk emerges.
Vorster42 shows how stroke has emerged as a major
public health problem amongst black South Africans,
possibly because of an increase in hypertension, obesity,
smoking habit and hyperfibrinogenaemia during various
stages of urbanisation. She also shows that black South
Africans may be protected against ischaemic heart disease
(IHD) because of favourable serum lipid profiles. Her
paper focuses on the role of urbanisation and provides
some sense of the importance of this factor in many
countries. Her paper also poses issues that arise as we are
attempting to understand the myriad of ways that different
sub-populations are found to be more and less vulnerable
to various shifts in diet, activity and body composition.
Can we turn back the clock or modify the adverse
dynamics? Programme and policy issues
This section contains a series of papers focused on the
early efforts in low- and moderate-income countries to
prevent many of the most adverse dimensions of the rapid
shift to the NR-NCD pattern. The general message is that a
combination of national and local efforts focused on
changes not only in the economic and physical
environment, but also use of mass media and various
settings (work, school, community), is needed to create
the wide-scale changes needed.
Puska et al.43 provide a clear example of how an
integrated approach to dietary change can affect the
structure of the diet and reduce NR-NCDs considerably.
They focus on the need for intersectoral collaboration with
one responsible national agency as the focal point. They
then lay out how, in Finland, national price policy and
food-labelling policies were combined with nutrition
education programmes, with the enlistment of voluntary
organisations, to tackle this effort. The authors discuss the
need to involve industry at national and international level
also. The paper shows how research and demonstration
efforts also comprise important elements in the large-scale
effort needed.
Matsudo and co-workers44 present some of the key
elements used to launch a mass promotion of physical
activity in Sao Paulo, Brazil. Termed the Agita Sao Paulo, it
began as a multi-level, community-wide intervention
designed to increase knowledge about the benefits and
the level of physical activity in a mega-population of 34
million inhabitants of Sao Paulo State, Brazil. It is being
expanded into a national effort slowly. Beginning with the
main message that 30 minutes per day, on most days of the
week, of moderate-intensity physical activity in one single
or in multiple sessions is important, the programme
encourages activity at home, leisure and in transport
between locations. It focuses all education materials and
efforts on a ‘one-step-ahead’ model. It has made
widespread use of population mass activity Agita days,
where millions walk, and a wide range of messages and
approaches to reach all socio-economic classes as
components. The Agita approach focuses on partnering
with many different sectors to empower persons of all
ages and classes. It is a new effort that started after the
reduction of obesity presented in the paper of Monteiro
et al.16. It promises to be an important dimension of the
Brazilian effort to improve diet and reduce
sedentarianism.
Zhai et al.45 and Coitinho et al.46 provide two important
overviews of China and Brazil, countries that have begun
to address this topic. China began in the late 1980s to
consider price policies and other food policies that might
retard or arrest the rapid shift towards an energy-dense
diet but did little else in the last decade. The Chinese
Academies of Agricultural Sciences and Preventive
Medicine (including as a key component the Institute of
Nutrition and Food Hygiene) and the State Council met in
one international meeting to review evidence in 1990
regarding the shift in structure of the Chinese diet and
patterns of morbidity and mortality. Now they have begun
to consider a wide-ranging set of activities in nutrition and
other sectors to address the very rapid increase of NR-NCD
Overview of the nutrition transition and its health implications 101
seen in China. In the health sector, efforts related to
reducing hypertension and diabetes are becoming more
widespread, but there is limited work in the nutrition
sector aside from the creation of dietary guidelines. This
paper points to some unique strengths from past Chinese
efforts and to an agenda for the next several decades.
In Brazil, a more co-ordinated and systematic effort is
underway. The effort began more recently but has created
a number of important legislative and regulatory policies,
revised one very large school-feeding programme and
done much to focus on the national policy environment.
At the same time efforts at mass communication – directly
via the mass media and through schools and food stores –
are underway. Furthermore, efforts at long-term capacity
building have begun. The effort of Matsudo et al.44 noted
above is a key component of this effort.
Doak47 summarises some of the NR-NCD programme,
policy and monitoring efforts underway in the countries
represented by the Bellagio meeting. The focus was on
large-scale efforts. As she shows, there are few of these.
There were few exemplary national efforts. One was the
national initiative in Thailand in public schools to promote
a more healthful diet and more physical fitness and
activity.
The Bellagio Declaration and other final points
This conference focused on the discussion of a topic that
really has only come to the public attention in a serious
way in the last decade. The group felt it was very
important to create a consensus declaration that spoke to
the essence of the discussions. At the end of the
supplement we publish this declaration. This addresses
how NR-NCDs are now the main causes of disability and
death, not only globally but also in most developing
countries. The critical focus was on prevention. The group
unanimously felt that prevention is the only feasible
approach to addressing this epidemic of nutrition-related
chronic diseases. The cost of their treatment and manage-
ment imposes an intolerable economic burden on
developing countries. There is an urgent need for
governments, in partnership with all relevant constitu-
encies, to integrate strategies to promote healthful diets
and regular physical activity throughout life into all
relevant policies and programmes, including those
designed to combat undernutrition.
The Bellagio conference and this supplement were
supported by a number of important funding sources. First
and foremost was the World Cancer Research Fund, which
provided an important seed grant for this meeting. Second
were the Rockefeller Foundation and the Bellagio Study
and Conference Center. The Foundation provided funding
for travel for persons from selected lower-income
countries and also provided a unique and wonderful but
isolated setting for the accommodations of all participants
and spectacular accommodation. Third was important
funding for publications and travel from the Carolina
Population Center, University of North Carolina at Chapel
Hill (UNC-CH), and two of my grants. We thank the
Fogarty International Center (TW/HD00633) and the
National Institutes of Health (NIH) (R01-HD38700) for
added support.
A number of persons were most instrumental in
organising and implementing the meeting. Foremost was
my administrative assistant, Ms Frances Dancy, who
handled all travel and logistics for the attendees. Mr Bill
Shapbell edited and organised the papers in a most timely
and excellent manner. Mr Tom Swasey edited graphics for
the final publications. Several UNC-CH Doctoral candi-
dates, Ms Soowon Kim, Ms Colleen Doak and Ms Samara
Nielsen, provided invaluable assistance at various stages.
Ms Doak is also thanked for helpful comments on this
introduction. Carlos Monteiro came to Chapel Hill to assist
in preparing the final agenda and handling many papers
and other scientific issues. Geoffrey Cannon was a major
force of encouragement and vision in the early stages. I
thank all of these persons.
Of course, all of the participants, who are the first
authors of all of the papers in this volume, were the key
elements in this meeting and publication. Their interest,
encouragement and active involvement were critical to the
success of this activity.
For further information and access to publications and
other materials from the Bellagio meeting, including slide
presentations, go to the Nutrition Transition Program
website: www.nutrans.org or www.nutritiontransition.org.
Barry M Popkin
Professor of Nutrition, Carolina Population Center, CB #
8120 University Square, University of North Carolina at
Chapel Hill, Chapel Hill, NC 27516-3997, USA
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